Disease Status and Interval between Hematopoietic Cell Transplantations Predict Outcome of Pediatric Patients Who Undergo Subsequent Transplantation for Relapsed Hematologic Malignancy

Patients with hematologic malignancies who relapse after allogeneic hematopoietic cell transplantation (HCT) have a poor prognosis. Although proceeding to subsequent HCT can provide potential for long-term survival, there are limited data to guide which patients are most likely to benefit and which HCT strategies are best in this heavily pretreated population. The goals of this study were to describe the clinical outcomes of subsequent HCT in pediatric patients with relapsed hematologic malignancies in a cohort enriched for haploidentical donors, and to evaluate the associations of patient-, disease-, and treatment-related factors with survival. We retrospectively evaluated patients who underwent a subsequent HCT for management of post-HCT relapse at a single institution between 2000 and 2021. Among 106 patients who underwent a second allogeneic HCT, the 1-year event-free survival (EFS) was 34% and 1-year overall survival (OS) was 46%, with a 5-year EFS of 26% and 5-year OS of 31%. Only disease-related factors were associated with outcome after second HCT-specifically, the interval between HCTs and the presence or absence of active disease at the time of HCT. In this cohort, patient- and treatment-related factors were not associated with differences in EFS or OS. Patients undergoing a third or fourth HCT (n = 13) had comparable survival outcomes to those undergoing a second HCT. Our experience highlights that a subsequent HCT has curative potential for a subset of patients who relapse after HCT, including those who undergo a subsequent HCT from a haploidentical donor. Although relapse and treatment-related toxicities remain major challenges, our study indicates that achieving complete remission prior to subsequent HCTs has the potential to further improve outcomes.

Retrospective analysis of veno-occlusive disease/sinusoidal obstruction syndrome in paediatric patients undergoing hematopoietic cell transplantation -a multicentre study

Background

Sinusoidal obstruction syndrome is a potentially fatal complication following hematopoietic cell transplantation, high-intensity chemotherapies and increasingly seen with calicheamicin based leukemia therapies. Paediatric specific European Society for Blood and Marrow Transplantation (pEBMT) diagnostic criteria have demonstrated benefit in single center studies compared to historic criteria. Yet, the extent to which they have been universally implemented remains unclear.

Methods

We conducted a retrospective multi-centre study to examine the potential impact of the Baltimore, modified Seattle and pEBMT criteria on the incidence, severity, and outcomes of sinusoidal obstruction syndrome among paediatric hematopoietic cell transplantation patients.

Findings

The incidence of sinusoidal obstruction syndrome in this cohort (n = 488) was higher by pEBMT (21.5%) vs historic modified Seattle (15.6%) and Baltimore (7.0%) criteria (p < 0.001). Application of pEBMT criteria identified 44 patients who were not previously diagnosed with sinusoidal obstruction syndrome. Overall, 70.5% of all patients diagnosed with sinusoidal obstruction syndrome ultimately developed very severe disease and almost half of diagnosed patients required critical care support. Overall survival was significantly lower in patients who were diagnosed with sinusoidal obstruction syndrome vs those who were not.

Interpretation

Taken together, pEBMT criteria may be a sensitive method for prompter diagnosis of patients who subsequently develop severe/very severe sinusoidal obstruction syndrome. To our knowledge, this is the first multi-centre study in the United States (US) to demonstrate that pEBMT guidelines are associated with earlier detection of sinusoidal obstruction syndrome. Since early initiation of definitive treatment for sinusoidal obstruction syndrome has been associated with improved survival in paediatric patients and implementation of pEBMT criteria appears feasible in the US, universal adoption should facilitate prompter diagnosis and lead to improved outcomes of children with sinusoidal obstruction syndrome.

Funding

None.

Spinal cord vascular degeneration impairs duloxetine penetration

Introduction

Chronic pain is a prevalent physically debilitating health-related morbidity. Frontline analgesics are inadequate, providing only partial pain relief in only a proportion of the patient cohort. Here, we explore whether alterations in spinal cord vascular perfusion are a factor in reducing the analgesic capability of the noradrenaline reuptake inhibitor, duloxetine.

Method

An established rodent model of spinal cord vascular degeneration was used. Endothelial-specific vascular endothelial growth factor receptor 2 knockout mouse was induced via hydroxytamoxifen administered via intrathecal injection. Duloxetine was administered via intraperitoneal injection, and nociceptive behavioural testing was performed in both WT and VEGFR2KO mice. LC-MS/MS was performed to explore the accumulation of duloxetine in the spinal cord in WT and VEGFR2KO mice.

Results

Spinal cord vascular degeneration leads to heat hypersensitivity and a decline in capillary perfusion. The integrity of noradrenergic projections (dopa - hydroxylase labelled) in the dorsal horn remained unaltered in WT and VEGFR2KO mice. There was an association between dorsal horn blood flow with the abundance of accumulated duloxetine in the spinal cord and analgesic capacity. In VEGFR2KO mice, the abundance of duloxetine in the lumbar spinal cord was reduced and was correlated with reduced anti-nociceptive capability of duloxetine.

Discussion

Here, we show that an impaired vascular network in the spinal cord impairs the anti-nociceptive action of duloxetine. This highlights that the spinal cord vascular network is crucial to maintaining the efficacy of analgesics to provide pain relief.

347 LONELINESS AMONGST OLDER INPATIENTS IN THE CONTEXT OF COVID-RELATED VISITING RESTRICTIONS

Background

Loneliness can affect people at all stages of life, but appears to be more closely linked to adverse health outcomes such as quality of life and healthcare use amongst older people. There are concerns that restrictions on hospital visits due to infection control policies related to the COVID-19 pandemic may exacerbate loneliness amongst older inpatients. The aim of this study is to quantify the burden of loneliness amongst older inpatients on a specialist geriatric medicine unit.

Methods

The study site is a large urban university teaching hospital with a 150-bed specialist geriatric medicine unit, comprising acute medical, rehabilitation and long-stay wards. The University of California, Los Angeles (UCLA) Scale was used to measure symptoms of loneliness with scores≥43 indicating high levels of loneliness.

Results

Over 84% of patients were lonely at some time while in hospital, with over one-third (24/76) reporting high levels of loneliness. The mean number of days since last visit from a relative or friend for patients reporting high degrees of loneliness was 11.4 (1.2 – 21.6) days, compared to 5.2 (3.2 – 7.1) days for those with reporting lower levels or no loneliness, though confidence intervals overlapped (p = 0.108). Similarly, patients with higher levels of loneliness had a longer length of stay (68.2 (49.4 – 87.1) compared to 47.9 (33.1 – 62.6) but again findings did not reach significance (p = 0.098). Linear regression models, controlling for competing covariates, found that depressive symptoms, were independently associated with burden of loneliness with a β-Coefficient = 10.69 (5.00 – 16.39).

Conclusion

Loneliness is particularly prevalent amongst older inpatients, with a trend towards higher levels of loneliness in those with less frequent visits. Interventions to help older people stay in touch with family and friends, and maintain social connectedness while in hospital, allowing for COVID-related restrictions, would be welcome, particularly for those with longer lengths of stay.

315 “I JUST GOT ON WITH IT”: EXPLORING THE PATIENT EXPERIENCE OF STROKE REHABILITATION DURING THE COVID-19 PANDEMIC

Background

There are emerging studies examining the pandemic experiences for older adults and healthcare staff, however the impact of COVID-19 on stroke rehabilitation has yet to be examined. Family involvement and social support is central to adjustment during stroke rehabilitation and this was impacted by the pandemic and its restrictions. The aim of this study was to explore first-person lived experiences of stroke rehabilitation in an Irish rehabilitation hospital setting during the COVID-19 pandemic and understand how COVID-19 restrictions impacted on patients’ experiences of stroke rehabilitation.

Methods

A qualitative descriptive design was implemented with a purposive sample of stroke survivors, who had undergone stroke rehabilitation between January – December 2021 at an Irish post-acute rehabilitation hospital. Semi-structured interviews were used as the primary data collection method and were audio-recorded and transcribed verbatim. Data were analysed using Braun & Clarke’s (2018) six-step approach and external data validator was used for inter-coder reliability.

Results

Eight stroke survivors were interviewed (male n=5, female n=3). Four main themes were identified: (i) Resilience and coping, (ii) Feeling supported along the journey, (iii) The pinch of COVID-19, (iv) Adjustment and moving on. The stroke survivors’ resilience was an important recurring theme throughout the analysis. A sense of feeling supported by hospital staff and peers was also prominent. The impact of COVID-19 restrictions was felt by all participants, however, resilience, support from hospital staff and peers were the strongest recurring themes.

Conclusion

COVID-19 restrictions had an impact on the stroke rehabilitation experience, however, stroke survivors felt well-supported and showed resilience in spite of this. To the best of the researchers’ knowledge, this is the first study which examines first-person accounts of stroke survivors during the COVID-19 pandemic, thus offering a unique perspective on the experiences of this cohort, who were hospitalised during this time.

345 HOW PREVALENT ARE UNDETECTED DEPRESSIVE SYMPTOMS AMONGST OLDER HOSPITAL INPATIENTS?

Background

Depression in later life can have a profound effect on quality of life, functional independence, healthcare use and early mortality. For multiple reasons however, depression in later life may often go undetected. The aim of this study is to ascertain the point prevalence of depressive symptoms on a specialist geriatric medicine unit, examining the rate of detection of clinically significant symptoms.

Methods

The study site is a large urban university teaching hospital with a 150-bed specialist geriatric medicine unit, comprising acute medical, rehabilitation and long-stay wards. Depressive symptoms were assessed using the Centre for Epidemiological Studies Depression Scale (CES-D) with a score ≥16 indicating significant symptoms. Medical notes were examined for documentation of screening for/assessment of depression since admission. Patients were included if they were aged ≥70 years, a current inpatient and able to give informed consent.

Results

Almost 62% (47/76) of the study sample (Mean age 83 years, 66% female) met criteria for significant depressive symptoms. Almost-half (23/47, 49%) of patients with significant depressive symptoms were screened for depression (either with a structured screening tool, a documented mood assessment or review by psychiatry) while in hospital. The mean length of stay for patients with depressive symptoms who had not yet been screened for depression was 42.7 (23.2 – 62.2) days and over 70% had been in hospital for at least 10 days, with almost two-thirds (15/24, 65%) currently residing on an acute geriatric medicine ward (rather than a rehabilitation or long stay ward).

Conclusion

Our study demonstrates a high burden of depressive symptoms amongst older inpatients, with almost 2 in 3 meeting criteria for clinically significant symptoms. Less than half of those with clinically significant symptoms were screened for depression however, representing an important missed opportunity to identify, and possibly treat, depression.

Sub-myeloablative Second Transplantations with Haploidentical Donors and Post-Transplant Cyclophosphamide have limited Anti-Leukemic Effects in Pediatric Patients

Pediatric patients with high-risk hematologic malignancies who experience relapse after a prior allogeneic hematopoietic cell transplant (HCT) have an exceedingly poor prognosis. A second allogeneic HCT offers the potential for long-term cure but carries high risks of both subsequent relapse and HCT-related morbidity and mortality. Using haploidentical donors for HCT (haploHCT) can expand the donor pool and potentially enhance the graft-versus-leukemia effect but is accompanied by a risk of graft-versus-host disease (GVHD). The goal of this protocol was to intensify the antileukemia effect of haploHCT for pediatric patients with hematologic malignancies that relapsed after prior allogeneic HCT, while limiting regimen-associated toxicities. This phase II clinical trial evaluated a sub-myeloablative preparative regimen consisting of anti-thymocyte globulin, clofarabine, cytarabine, busulfan, and cyclophosphamide, in combination with plerixafor to sensitize leukemic blasts. Participants received a mobilized peripheral blood unmanipulated haploidentical donor graft with one dose of post-transplant cyclophosphamide as GVHD prophylaxis, followed by natural killer (NK) cell addback. Here we report the clinical outcomes and immune reconstitution of 17 participants treated on the study and 5 additional patients treated on similar single-patient treatment plans. Of the 22 participants analyzed, 12 (55%) had active disease at the time of HCT. The regimen provided robust immune reconstitution, with 21 participants (95%) experiencing neutrophil engraftment at a median of 14 days after HCT. In this high-risk population, the overall survival was 45% (95% confidence interval [CI], 24%-64%), with a 12-month event-free survival of 31% (95% CI, 14%-51%) and cumulative incidence of relapse at 12 months of 50% (95% CI, 27%-69%). Four participants (18%) remain in remission at >5 years follow-up. Expected HCT-related organ-specific toxicities were observed, and 13 participants (59%) experienced acute or chronic GVHD. This intensified but sub-myeloablative regimen, followed by a high-dose unmanipulated haploidentical graft, post-transplantation cyclophosphamide, and NK cell infusion, resulted in adequate immune reconstitution but failed to overcome the elevated risks of relapse and treatment-related morbidity in this high-risk population.

Outcome of Acute Respiratory Failure Secondary to Engraftment in Children After Hematopoietic Stem Cell Transplant

Introduction: Respiratory complications due to engraftment syndrome (ES) in the post-hematopoietic stem cell transplant (HSCT) setting can lead to acute respiratory failure (ARF). Outcomes of children developing ARF due to engraftment are unknown.

Methods: We conducted a retrospective analysis of 1,527 pediatric HSCT recipients and identified children who developed ARF due to ES over a 17-year period. Thirty patients that developed ARF and required invasive mechanical ventilation (IMV) due to ES were included in this study.

Results: The survival rate for our cohort was 80% [alive at intensive care unit (ICU) discharge]. The most common underlying primary disease was hematologic malignancy, and 67% of children underwent allogeneic HSCT. Further, 73% required vasopressor drips and 23% underwent dialysis. Survivors had a shorter median ICU length of stay than did non-survivors (15 vs. 40 days, respectively, p = 0.01). Survivors had a significantly lower median cumulative fluid overload % on days 4 and 5 after initiation of IMV than did non-survivors (2.8 vs. 14.0 ml/kg, p = 0.038 on day 4, and 1.8 vs. 14.9 ml/kg, p = 0.044 on day 5, respectively).

Conclusion: Our results suggest that children who develop ARF during engraftment have better ICU survival rates than do those with other etiologies of ARF post-HSCT. Furthermore, fluid overload contributes to mortality in these children; therefore, strategies to prevent and address fluid overload should be considered.

Improved survival rate in T-cell depleted haploidentical hematopoietic cell transplantation over the last 15 years at a single institution

T-cell depletion of an HLA-haploidentical (haplo) graft is often used to reduce the risk of graft-versus-host disease (GVHD), but the lack of donor T cells in the infused product may lead to graft failure, slow T-cell reconstitution, infections, and relapse. More selective T-cell depletion targeting CD45RA can effectively deplete naïve T cells but preserve large numbers of memory T cells leading to robust engraftment of diverse T-cell populations and reduction of viremia in the early post-transplant period. Herein, we report the outcome of 143 pediatric and young adult hematologic malignancy patients receiving a first allogeneic hematopoietic cell transplantation (HCT) on 6 consecutive ex vivo T-cell depleted haploHCT protocols over the past 15 years at a single institution - including the first 50 patients on an active CD45RA-depleted haploHCT study in which patients also received NK-cells and pharmacological GvHD prophylaxis post transplant. Our data demonstrated an increase in the 3-year overall survival and event-free survival in non-chemorefractory recipients receiving CD45RA-depleted grafts (78.9% and 77.7%, respectively) compared to historic T-cell depleted haploHCT cohorts (46.7% and 42.7%, respectively, p=0.004, and 0.003). This improvement was primarily due to a reduction in transplant related mortality without significant increase in the rates of GVHD.

Secondary hemophagocytic syndrome after autologous hematopoietic cell transplant and immune therapy for neuroblastoma

Secondary hemophagocytic syndrome (HPS) has been described after autologous hematopoietic cell transplant (AutoHCT). We report two cases of secondary HPS after novel consolidation therapy for high-risk neuroblastoma as part of an institutional phase 2 trial incorporating immunotherapy into a "standard" AutoHCT regimen. Both patients developed liver dysfunction beyond expected course of hepatic veno-occlusive disease, coagulopathy, hyperferritinemia, and when evaluated, elevated soluble interleukin-2 receptor and hemophagocytosis. These cases highlight the need for clinicians to have a high index of suspicion for immune-related complications in patients receiving immune therapies.

London Trauma Conference 2015

I1: Trauma, Pre-hospital and Cardiac Arrest Care 2015

Pascale Avery, Leopold Salm, Flora Bird

A1: Retrospective evaluation of HEMS ‘Direct to CT’ protocol

Anja Hutchinson, Ashley Matthies, Anthony Hudson, Heather Jarman

A2 Rush hour – Crush hour: temporal relationship of cyclist vs. HGV trauma admissions. A single site observational study

Maria Bergman Nilsson, Tom Konig, Nigel Tai

A3 Semiprone position endotracheal intubation during continuous cardiopulmonary resuscitation in drowned children with regurgitation: a case report and experimental manikin study

Espen Fevang, Børge Hognestad, Håkon B. Abrahamsen

A4 An audit of CO2 A-a gradient in non-trauma patients receiving pre-hospital anaesthesia

Olivia V Cheetham, Matthew JC Thomas, Kieron D Rooney

A5 Can the use of c-spine immobilisation collars be avoided in non-trauma patients presenting to the Emergency Department?

Josephine Murray, Malcolm Tunnicliff

A6 Curriculum mapping in ED point of care simulation

Joseph W Collinson, Thomas Brown, Christopher Pritchett

A7 Point of care multidisciplinary trauma team simulation & participant satisfaction in a geographically remote trauma unit in Cornwall

Christopher SA Pritchett, Mark Jadav, Gareth Meredith, Jamie Plumb, Steve Harris, Roger Langford

A8 Conservative management of head injury inpatients - the challenge of simplifying injury management in a non-neurosurgical hospital

JG Hunter, A Sage, R Madden, O Flamank, B Broadbent, S Marsh, H Lewis, E Daniels, N Roberts

A9 Improving the care of traumatic brain injury at non-neurosurgical hospitals: Introducing a head injury pathway and single place of care is associated with significant improvements in neurological observation

JG Hunter, A Sage, R Madden, O Flamank, B Broadbent, S Marsh, H Lewis, E Daniels, N Lin, N Roberts

A10 The experience of inter-disciplinary students undertaking cardiac arrest moulage training

Samuel Bulford, Silas Houghton-Budd, Sam Pearson, Megan Clear-Hill

A11 Impact brain apnoea – nine cases

David J Menzies, James P Leonard, Conor Keogh, Ray Quinn, John D Hinds

A12 Time well spent? Improving the performance improvement programme in a busy Trauma Unit

N Roberts, D Ashton-Cleary, M Jadav

A14 Clinical significant and outcome of pulmonary contusions in patients with blunt chest trauma

Ismail Mahmood, Ayman El-Menyar, Basil Younis, Ahmed Khalid, Syed Nabir, Mohamed Nadeem Ahmed, Omer Al-Yahri, Hassan Al-Thani

A15 Plastics operative workload in major trauma centres: a national prospective survey

Katie Young, Susan A. Hendrickson, Georgina Phillips, Matthew D. Gardiner, Shehan Hettiaratchy

A16 A survey to assess the accuracy of estimating height by pre-hospital clinicians: can we reliably predict those most at risk of serious injury?

Alexandra Alice Crossland, Anthony Hudson

A17 An audit of the cause, outcome and adherence to treatment Standard Operating Procedure (SOP) for all traumatic cardiac arrests at a Helicopter Emergency Medical Service over a 12-month period

Nicholas C Brassington, Anthony Hudson, Emily McWhirter

A18 Should we “stay-and-play? A study of patient physiology in Norwegian Helicopter Emergency Services

Bjørn O Reid, Marius Rehn, Oddvar Uleberg, Andreas J Krüger

A19 Training in resuscitative thoracotomy: have we cracked it? A survey of higher Emergency Medicine trainees in London

Cara Jennings, Yasmin Kapadia, Duncan Bew

A20 London’s Air Ambulance (LAA): 25-years of drownings in an urban environment

Jenny Townsend, Tom P Hurst, Elizabeth A Foster

A21 Live patients in trauma simulation – more than just simulation on a shoestring?

Thomas B Brown, Joseph Collinson, Christopher Pritchett, Toby Slade

A22 Collecting core data in pre-hospital critical care using a consensus based template

Kristin Tønsager, Marius Rehn, Kjetil G.Ringdal, Andreas J.Krüger

A23 Prehospital interventions before and after implementation of a physician staffed helicopter

Rasmus Hesselfeldt, Sandra Wulffeld, Asger Sonne, Lars S. Rasmussen, Jacob Steinmetz

A24 Duration of ventilation following prehospital drug assisted intubation; a retrospective review

Thomas J Renninson, Nadine Thomson, Harvey Pynn, Timothy J Hooper

A25 Non-haemorrhagic shock in trauma: a novel guideline for management in ED

Anthony Hudson, Jacinta Dawson, Ashley Matthies

A26 Patient-tailored triage decisions by anaesthetist-staffed pre-hospital critical care teams

Morten Langfeldt Friberg, Leif Rognås

A27 Anatomical accuracy and appropriate sizing of pre-hospital thoracostomies

Jessica FG Wills, Anthony Hudson

A28 Pre-hospital management of mass casualty civilian shootings

Conor DA Turner, Marius Rehn

A30 The prevalence of alcohol-related trauma recidivism: a systematic review

James Nunn, Mete Erdogan, Robert S. Green

A31 Development of a hospital-wide program for simulation-based training in trauma care and management

Samuel Minor, Mete Erdogan, Kathy Hartlen, Robert S. Green

A32 Out of Hospital Cardiac Arrests (OOHCA); lessons from Hollywood

Ruth Bird, Rachael L. Grupping

A33 Mechanism of injury as a predictor of severity of injury in road traffic collisions: a literature review

Amelia M. Stacey, Marius Rehn, David J. Lockey

A34 Lessons to be learned from prehospital airway intervention documentation? Are airway intervention documentation templates as successful in-hospital as prehospitally?

S. Abiks, L. Cutler, K. Monaghan, A. Al-Rais, C. Hymers, R. Bloomer, Y. Kapadia

A35 Novel biomarkers in prehospital management of traumatic brain injury (the PreTBI study protocol)

Sophie-Charlott Seidenfaden, Ingunn S. Riddervold, Hans Kirkegaard, Niels Juul, Morten T. Bøtker

A36 Hospital outcomes of traumatic railway incidents: a seven-year observational retrospective study of a major trauma centre

Alice Gao, Zane Perkins; Gareth Grier, Alex Tzannes

A37 Does taking a third crew member affect the on-scene time of HEMS jobs?

Nathan Hudson-Peacock, Quentin Otto, Laurie Phillipson, Rik Thomas, Ainsley Heyworth

A38 Does pre-hospital rapid sequence induction affect on-scene time of HEMS jobs?

Quentin Otto, Nathan Hudson-Peacock, Laurie Phillipson, Ainsley Heyworth, Erica Ley

A39 Code red: shock index as a prehospital indicator of massive haemorrhage

Daniel Banner, Ainsley Heyworth, Erica Ley

A40 Air ambulance tasking: how accurate are our current methods?

Madeleine Benson, Nathan Hudson-Peacock, Tony Stone, Erica Ley, Louise Rousson, Ainsley Heyworth

A41 Modern trauma burden in a district general hospital

Beth A Lineham, Matthew J Lee, Martin Gough

A42 Establishing a legal service for major trauma patients in two UK major trauma centres

William H Seligman, Hannah E Thould, Andrew Dinsmore, Charlotte Tan, Julian Thompson, C Andy Eynon, David J Lockey

A43 Prehospital assessment and care of patients – a study of the use of guidelines when assessing head trauma

Rebecka M Rubenson Wahlin, Veronica Lindström, Sari Ponzer, Veronica Vicente

A44 An audit of pre-hospital blood pressure management resulting from head injury

Pamela Eligio, Anthony Hudson

A45 The surgical contribution of surface shading volumetric rendering techniques in rib fracture management

Robert Young, Dimitri Amiras, Ian Sinha

To fast or feed: an alternative life history for anadromous brook trout Salvelinus fontinalis overwintering within a harbour

The seasonal feeding pattern of sea-run brook trout Salvelinus fontinalis was studied from November to May 2010-2012 in Antigonish Harbour, Nova Scotia, Canada (45° 38' N; 61° 55' W). Sixty-three S. fontinalis (mean ± s.d. fork length = 330 ± 70 mm and mass = 536 ± 351 g) captured had fed predominantly on fishes (Fundulidae and Gasterosteidae). Percentage of empty stomachs was highest during autumn (18%) and winter (22%) and lowest in spring (7%). Stomach fullness increased from autumn to a maximum during winter, relating to near-zero body temperatures which may have effectively stopped gastric evacuation. Although feeding occurred during winter (December to March), consumption rates were calculated as negative values, and subsequently returned to positive values in spring (April to May). The over-winter life-history strategy of this sea-run S. fontinalis population appears to be a feeding marine migration in which fish continually increase body condition, representing an alternative to the more common overwintering strategy of starvation in fresh water until spring.

Site-dependent changes in structure and function of lapine articular cartilage 4 weeks after anterior cruciate ligament transection

OBJECTIVE

The aim of this study was to investigate the site-dependent changes in the structure and function of articular cartilage in the lapine knee joint at a very early stage of osteoarthritis (OA), created experimentally by anterior cruciate ligament transection (ACLT).

METHODS

Unilateral ACLT was performed in eight mature New Zealand white rabbits. ACL transected and contralateral (C-L) joints were prepared for analysis at 4 weeks after ACLT. Three rabbits with intact joints were used as a control group (CNTRL). Femoral groove, medial and lateral femoral condyles, and tibial plateaus were harvested and used in the analysis. Biomechanical tests, microscopy and spectroscopy were used to determine the biomechanical properties, composition and structure of the samples. A linear mixed model was chosen for statistical comparisons between the groups.

RESULTS

As a result of ACLT, the equilibrium and dynamic moduli were decreased primarily in the femoral condyle cartilage. Up to three times lower moduli (P < 0.05) were observed in the ACLT group compared to the control group. Significant (P < 0.05) proteoglycan (PG) loss in the ACLT joint cartilage was observed up to a depth of 20-30% from the cartilage surface in femoral condyles, while significant PG loss was confined to more superficial regions in tibial plateaus and femoral groove. The collagen orientation angle was increased (P < 0.05) up to a cartilage depth of 60% by ACLT in the lateral femoral condyle, while smaller effects, but still significant, were observed at other locations. The collagen content was increased (P < 0.05) in the middle and deep zones of the ACLT group compared to the control group samples, especially in the lateral femoral condyle.

CONCLUSION

Femoral condyle cartilage experienced the greatest structural and mechanical alterations in very early OA, as produced by ACLT. Degenerative alterations were observed especially in the superficial collagen fiber organization and PG content, while the collagen content was increased in the deep tissue of femoral condyle cartilage. The current findings provide novel information of the early stages of OA in different locations of the knee joint.

Characteristics of Epstein-Barr virus hepatitis among patients with jaundice or acute hepatitis

BACKGROUND

Abnormal liver blood tests are common in Epstein-Barr virus (EBV) infection, but symptomatic hepatitis is rare. The demographics, clinical features and outcome of EBV hepatitis are incompletely understood, particularly in the elderly people.

AIM

To identify the demographics, presenting features and natural history of EBV hepatitis.

METHODS

Retrospective review of 1995 consecutive patients attending the jaundice hotline clinic over a 13-year period. Data collected included demographic information, presenting features, clinical and laboratory parameters, radiology imaging and clinical outcome.

RESULTS

Seventeen of 1995 (0.85%) had EBV hepatitis. The median age was 40 years (range 18-68 years). Ten of 17 (59%) patients were aged >30 years, and seven of 17 (41%) patients were aged ≥60 years. Fifteen of 17 (88%) patients presented with clinical/biochemical evidence of jaundice. Seventeen of 17 (100%) patients had a serum lymphocytosis at presentation. 2/17 (12%) patients with EBV hepatitis presented with the classical features of infectious mononucleosis (fever, sore throat and lymphadenopathy). Splenomegaly was present in 15/17 (88%) of patients. Symptoms lasted for a median 8 weeks (range 1-12 weeks). Three of 17 (18%) patients required a brief hospital admission.

CONCLUSIONS

In patients presenting with jaundice/hepatitis, EBV hepatitis is an uncommon diagnosis and causes a self-limiting hepatitis. The diagnosis is suggested by the presence of a lymphocytosis and/or splenomegaly. The majority of patients do not have infectious mononucleosis. Compared with infectious mononucleosis, EBV hepatitis affects an older age group, with nearly half of patients being aged more than 60 years. The diagnosis should be considered in all patients with unexplained hepatitis irrespective of their age.

High white blood cell concentration in the peripheral blood stem cell product can induce seizures during infusion of autologous peripheral blood stem cells

Seizures as a complication of the infusion of autologous peripheral blood stem cells (PBSC) are rare. Seizures during infusion of autologous PBSC in 3 of our patients prompted us to review our cell therapy and cytapheresis protocols and procedures. We retrospectively analyzed 159 adult patients collected between January 2006 and July 2009. Patients were collected on either the COBE Spectra (Caridian BCT, Lakewood, CO) cell separator (n = 85) or Fresenius AS (Fresenius Kabi AG, Bad Homburg, Germany) 104 cell separator (n = 74) and mobilized with granulocyte-colony stimulating factor (G-CSF) alone (n = 47), G-CSF and Plerixafor (n = 36), or G-CSF and chemotherapy (n = 76). Patient characteristics (including age, weight, number of collections, volume processed, disease type, and mobilization strategy) did not differ significantly between the COBE and Fresenius cohorts, and adverse effects from infusion were similar except for 3 of 159 patients who experienced seizures upon infusion of PBSC; all 3 were collected on the COBE and had PBSC product white blood cell (WBC) counts of 590 × 10(3)/μL or above. We prospectively correlated WBC counts midcollection, with final WBC counts to identify products with high WBC concentration during cytapheresis. Fifty-one patients had 66 cytapheresis procedures using the COBE, with WBC counts midway and at the end of collection of 287 × 10(3) ± 150/μL and 273 × 10(3) ± 144/μL, respectively. Mid-WBC therefore correlated with WBC at the end of the collection. Finally, we prospectively collected mid-WBC from 65 patients who underwent 80 PBSC collections between June 2009 and January 2010 to identify products with midcollection WBC concentration >450 × 10(3)/μL. In those cases, additional autologous plasma was collected at the time of collection to dilute the final product before cryopreservation. Patients who received diluted products experienced no delays in engraftment and no additional seizure episodes occurred.

Determining the Oleic/linoleic Acid Ratio in a Single Peanut Seed: a Comparison of Two Methods

Peanut varieties with high oleic/linoleic acid ratios have become preferred by the peanut industry due to their increased shelf life and improved health benefits. Many peanut breeding programs are trying to incorporate the high oleic trait into new and improved varieties and are in need of diagnostic tools to track its inheritance early in development and at the single seed level. Traditionally, gas chromatography has been used to accurately determine the properties of peanut oil. Recently a method was developed to carry out this analysis by capillary elecrophoresis providing researchers with an alternative analytical platform. In this study, the use of capillary electrophoresis and gas chromatography for analysis of oleic/linoleic acid ratios are compared. Oil was extracted from approximately 0.10 g of peanut seed tissue taken from the distal end, leaving the embryonic end of the seed intact for subsequent germination. Over 100 samples inclusive of runner, Spanish and Virginia market types were processed. Oil extracts were analyzed for oleic/linoleic acid ratio using (1) capillary electrophoresis (CE) and (2) gas chromatography (GC). Results showed that the two methods are 100% in agreement in determining whether a peanut seed is “high-oleic” or “normal oleic” in oil content. Furthermore, the two methods are highly correlated (r  =  0.96; p &lt; 0.0001) with respect to determining the exact oleic/linoleic acid ratio from each sample. Results from this study validate the use of CE as a diagnostic tool for breeding programs to identify individual high oleic peanut seed for further testing and development.

Pyrosequencing and characterization of immune response genes from the American dog tick, Dermacentor variabilis (L.)

Ticks continue to be a threat to animal and human health, and new and novel control strategies are needed for ticks and tick-borne pathogens. The characterization of the tick-pathogen interface and the tick immune response to microbial infections is fundamental toward the formulation of new control strategies for ticks and the pathogens they transmit. Our overall hypothesis for this research is that the tick immune system manages the maintenance of pathogens. Therefore, discovery of tick immune response genes may provide targets for novel control strategies directed toward reducing vector competency and pathogen transmission. In these studies, 454 pyrosequencing, a high-throughput genomic sequencing method was used to discover tick genes expressed in response to bacterial and fungal infections. Expressed sequence tags (ESTs) were analysed from Dermacentor variabilis ticks that had been injected with bacteria (Escherichia coli, Bacillus subtilis, Micrococcus luteus) or fungi (Saccharomyces cerevisiae and Candida albicans) and ticks that were naturally infected with the intracellular bacterium, Anaplasma marginale. By this approach, ESTs were assembled into 5995 contigs. Contigs fell into the five main functional categories of metabolism, genetic information processing, environmental information processing, cellular processes and human diseases. We identified more than 30 genes that are likely to encode for proteins involved in tick immune function. We further analysed by reverse transcriptase PCR (RT-PCR) the expression of 22 of these genes in each of our bacterial or fungal treatment groups and found that seven were up-regulated. Up-regulation of these seven genes was confirmed for bacterial, but not fungal treatment by quantitative PCR (qPCR). One of these products was novel, encoding a new tick defensin. Our results clearly demonstrate the complexities of the tick immune system and mark new directions for further study and characterization of proteins that modulate microbial infections in the American dog tick.

Total and active rabbit antithymocyte globulin (rATG;Thymoglobulin) pharmacokinetics in pediatric patients undergoing unrelated donor bone marrow transplantation

Rabbit antithymocyte globulin (rATG; Thymoglobulin) is currently used to prevent or treat graft-versus-host disease (GVHD) during hematopoietic stem cell transplantation (HSCT). The dose and schedule of rATG as part of the preparative regimen for unrelated donor (URD) bone marrow transplantation (BMT) have not been optimized in pediatric patients. We conducted a prospective study of 13 pediatric patients with hematologic malignancies undergoing URD BMT at St. Jude Children's Research Hospital from October 2003 to March 2005, to determine the pharmacokinetics and toxicities of active and total rATG. The conditioning regimen comprised total body irradiation (TBI), thiotepa, and cyclophosphamide (Cy); cyclosporine (CsA) and methotrexate (MTX) were administered as GVHD prophylaxis. Patients received a total dose of 10 mg/kg rATG, and serial blood samples were assayed for total rATG by enzyme linked immunosorbent assay (ELISA) and active rATG by florescein activated cell sorting (FACS). We found that our weight-based dosing regimen for rATG was effective and well tolerated by patients. The half-lives of total and active rATG were comparable to those from previous studies, and despite high doses our patients had low maximum concentrations of active and total rATG. There were no occurrences of grade iii-iv GVHD even in patients having low peak rATG levels, and the overall incidence of grade II GVHD was only 15%. None of the patients had serious infections following transplantation. These data support the use of a 10 mg/kg dose of rATG in children with hematologic malignancies because it can be administered without increasing the risk of graft rejection, or serious infection in pediatric patients with a low rate of GVHD. These conclusions may not apply to patients with nonmalignant disorders.

A novel approach for quantification of KIR expression in healthy donors and pediatric recipients of hematopoietic SCTs

The killer cell Ig-like receptor (KIR) expression repertoire may offer valuable information for hematopoietic SCT (HSCT). We designed a quantitative KIR RNAtype assay and used it to determine KIR gene expression in healthy donors and patients before HSCT. The specificity of the assay was ensured by specific primers and by electrophoretic distinction of PCR products of unique length. In 87 healthy donors, the KIR repertoire was broadly distributed (32 categories of profiles). There was an overall trend toward inverse correlation of KIR expression level and donor age. Age affected mainly the activating KIR families. Leukemia patients showed lower KIR expression before transplantation than healthy donors. Stem cell mobilization caused a transient increase of KIR expression. We conclude that KIR expression differs quantitatively with age and primary disease and is transiently altered by stem cell recruitment and selection.

Clinical utility of computed tomography screening of chest, abdomen, and sinuses before hematopoietic stem cell transplantation: the St. Jude experience

All allogeneic (allo) and autologous (auto) hematopoietic stem cell transplantation (HSCT) recipients at St. Jude Children's Research Hospital undergo pre-HSCT computed tomography (CT) of the sinuses, chest, and abdomen because they are at significant risk for opportunistic infections. We studied whether this extensive routine imaging is warranted to detect infection despite the risk of additional radiation exposure. We reviewed the medical records of all children receiving allo- and auto-HSCT at St. Jude in 2004 and 2005. Of the 184 eligible patients who received 187 transplants, 131 received allografts and 56 autografts. Solid tumors and lymphomas were removed from the final analysis of the chest and abdomen CT as this imaging is typically warranted as part of disease restaging; thus, 111 allogeneic participants were included in this analysis. Both auto- and allo-recipients were evaluated by sinus CT and included in this final analysis. Most allo- and auto-HSCT recipients (> or =80%) did not have sinus, pulmonary, cardiac, or gastrointestinal symptoms; >85% of the evaluable allo-recipients had no prior fungal infection. Eighty-eight allo- and 31 auto-HSCT recipients had abnormal sinus CT findings, all unrelated to the underlying disease. Sixty-two (55.9%) of the allo-recipients had normal chest CT and 85 (76.6%) had normal abdominal CT. Of the 18 allo-recipients who began new therapy based on these findings, only 2 (11.1%) were related to chest CT findings and the other 16 were related to sinus findings. Our findings suggest that pre-HSCT routine CT imaging of the abdomen may not be warranted in a subset of allogeneic recipients who are asymptomatic and without previous infectious findings. Thus, these patients may be spared unnecessary radiation exposure. Recipients undergoing auto-HSCT or allo-HSCT for lymphomas or solid tumors will routinely undergo chest and abdominal CT imaging as part of their disease evaluation. The decision to perform chest CT should be made judiciously based on a careful history and physical examination. Sinus imaging, which was frequently abnormal, may be justified in all patients to plan post-HSCT care.

The WHO Family of International Classifications

The concept of the Family of International Classifications has been created to have a common framework and language to report, compile, use, and compare health information at the national and international level. The family brings together different health classifications dealing with various dimensions of health and health care so as to present a more comprehensive picture of health care. The family of classifications in health consists of reference classifications, derived ones and related ones. The reference classifications cover the areas of death and disease, disability and health interventions. Other members cover fields like drugs, causes of injury and reasons for encounter. These classifications represent the building blocks of health information in order to be able to provide the best possible health to all people.

Salmonella in slaughter pigs in Northern Ireland: prevalence and use of statistical modelling to investigate sample and abattoir effects

A cross-sectional survey of pigs at slaughter in Northern Ireland was undertaken to determine the overall prevalence of Salmonella infection. In total 513 pigs were sampled across four abattoirs, with Salmonella spp. isolated from the caecal contents of 31.4% (95% confidence interval [CI] 27.4%-35.4%) and from 40.0% (95% CI 35.8%-44.3%) of swabs taken from the surface of carcasses post-evisceration. Two serovars, S. Typhimurium and S. Derby, were predominant and accounted for 52% and 35% respectively, of isolates from caecal contents. Antimicrobial resistance was most common amongst isolates of S. Typhimurium with 63.9% multiresistant compared to 10.8% of S. Derby isolates and 8.0% of other Salmonella spp. The proportion of pigs showing serological evidence of infection was significantly lower, with 11.5% (95% CI 8.9%-14.6%) and 10.1% (95% CI 7.7%-13.1%) of meat-juice samples giving positive and suspect reactions, respectively. The ratio of caecal positive to serologically positive animals is higher than in a number of other studies and may suggest recent infection, such as infection occurring during transport or lairage, in a proportion of animals. Statistical (logistic regression) modelling was used to investigate the association between the risk of Salmonella on carcasses and the isolation of Salmonella from caecal contents, and/or the serological status of the animal, while adjusting for other possible explanatory and confounding variables such as abattoir, season, day and time of sampling. The occurrence of Salmonella in caecal contents (odds ratio [OR] 2.39; 95% CI 1.52-3.77) or a suspect/positive serological reaction (OR 2.15; 95% CI 1.28-3.61) were both independently associated with the occurrence of Salmonella on carcasses in homebred, but interestingly not in imported animals. In most multivariable models there were also significant differences in carcass contamination between seasons with the highest odds of carcass contamination occurring in the April to June quarter and the lowest in the October to December quarter. Differences between sampling days were also evident with the highest odds of carcass contamination at the end of the week (Fridays) and the lowest at the start of the week (Mondays). These associations, after adjusting for the caecal or serological result, would suggest the occurrence of abattoir effects, such varying residual levels of abattoir contamination, which are independent of the individual pig status.

Total body irradiation, fludarabine, melphalan, and allogeneic hematopoietic stem cell transplantation for advanced pediatric hematologic malignancies

We evaluated the efficacy and toxicity of adding 9 Gy of total body irradiation (TBI), in three single daily fractions of 3 Gy, to the reduced intensity regimen of fludarabine 30 mg/m2 i.v. x 4 days and melphalan 140 mg/m2 i.v. x 1 day in advanced pediatric hematologic malignancies. Twenty-two acute lymphoblastic leukemia (ALL), six acute myeloid leukemia (AML), and one non-Hodgkin lymphoma patients were transplanted. Of these, 13 were beyond second remission, and five had prior hematopoietic stem cell transplant (HSCT). Twenty-one donors were unrelated, of which 19 were from cord blood (CB) units. Three of the eight related donors were genotypically disparate. Oral mucositis and diarrhea were the most common toxicities. Twenty-seven patients achieved neutrophil engraftment (median 16 days), and 23 had platelet engraftment (median 42 days). One patient had primary graft failure. Seven patients died of non-relapse causes in the first 100 days. With a median follow-up of 52 months, seven of 22 ALL, five of six AML, and one of one lymphoma patients are alive and in remission. The regimen of TBI, fludarabine, and melphalan allows the engraftment of allogeneic hematopoietic stem cells (including mismatched CB). It was fairly well tolerated in pediatric patients, even for second transplants. Its efficacy requires further evaluation.

Clofarabine, a novel nucleoside analog, is active in pediatric patients with advanced leukemia

Despite progress in leukemia therapy, most children who experience relapse have a dismal prognosis. New, effective approaches are needed. We conducted a phase 1 study of a novel nucleoside analog, clofarabine, in pediatric patients with refractory and relapsed leukemia. Clofarabine was infused intravenously over 1 hour each day for 5 days. Six dose levels, between 11.25 and 70 mg/m(2) per day for 5 days, were studied in 25 patients. A modified 3 + 3 phase 1 design was followed with 30% dose escalation until the dose-limiting toxicity (DLT) was defined. The maximum tolerated dose (MTD) was 52 mg/m(2) per day for 5 days. At the end of infusion at MTD, clofarabine triphosphate levels in leukemia blasts varied between 6 microM and 19 microM, which resulted in complete and sustained inhibition of DNA synthesis. The DLT was reversible hepatotoxicity and skin rash at 70 mg/m(2) per day for 5 days. Twenty-five patients were treated. Five patients achieved complete remission (CR), and 3 achieved partial remission (PR), for an overall response rate of 32%. Clofarabine is well tolerated and shows significant antileukemic activity in heavily pretreated children. Multicenter phase 2 trials in pediatric acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML) are ongoing.

Use of cryopreserved cadaveric vein allograft for hemodialysis access precludes kidney transplantation because of allosensitization

BACKGROUND

Dimethyl sulfoxide-cryopreserved cadaveric vein allografts have recently been proposed as an alternative to prosthetic grafts in the problem hemodialysis population. The transfer of mismatched major histocompatibility complex I and II molecules in association with these allografts can potentially lead to allosensitization in nonimmunosuppressed individuals.

METHODS

In a university-affiliated medical center, 20 consecutive patients receiving technically successful upper arm cadaveric vein allograft fistulas (CAVFs) for hemodialysis between April 1999 and April 2000 were studied. A control cohort of 20 patients on a kidney transplantation waiting list was selected by nurses blinded to the study. These patients were matched for age, sex, history of transfusion, pregnancy, cause of kidney failure, and prior transplantation. The panel reactive antibody (PRA) values were recorded in this group over the same time period as the CAVF group.

RESULTS

Patients receiving CAVFs had a mean PRA assay value of 84.1% (median, 96.5%) at an average of 3.1 months after engraftment (median, 1.5 months). The preengraftment PRA values were available for seven patients who were on the transplant waiting list. Six of these patients had nonreactive PRA assays before CAVF creation. All of these patients converted to positive PRA assays after CAVF creation with a mean value of 92.3% (median, 98%) at 2.85 months follow-up (median, 1.3 months). The mean PRA value for the control cohort was 5.5% (median, 2.5%), with no patients converting from a nonreactive to a reactive PRA assay during this same time interval.

CONCLUSION

The use of dimethyl sulfoxide-cryopreserved cadaveric vein allografts for hemodialysis access leads to broad allosensitization as measured by PRA assay. Cryopreserved cadaveric vein allografts should not be used for hemodialysis access in potential kidney transplant recipients.

Adenine phosphoribosyltransferase deficiency and renal allograft dysfunction

Adenine phosphoribosyltransferase (APRT) deficiency is a rarely diagnosed cause of renal allograft dysfunction. We report the case of a 42-year-old man who presented in 1996 with idiopathic renal failure. Native kidney biopsy showed extensive microcrystalline interstitial nephritis. The patient subsequently underwent a living-related kidney transplant with excellent early graft function. During the next year, however, he had worsening allograft function, and allograft biopsy showed recurrent interstitial nephritis. Further chemical and spectroscopic analysis showed this lesion to be an annular microcrystalline nephritis consistent with APRT deficiency. This diagnosis was confirmed on erythrocyte assay. Treatment with allopurinol and a low-purine diet led to improvement and stabilization of renal function. APRT is a rare cause of renal allograft dysfunction requiring a high index of suspicion for early diagnosis and treatment. Increased physician awareness in the United States may hasten diagnosis and limit the morbidity associated with this disease.

Complementary and alternative medicine use among children in the Washington, DC area

OBJECTIVE

To determine the prevalence and reasons for complementary and alternative medicine (CAM) use among children in primary pediatric care practice in the Washington, DC area.

DESIGN

Cross-sectional survey of parents at 4 Children's National Medical Center Pediatric Research Network (PRN) practices from July 1998 through November 1998. Survey information included demographics, child health problems, satisfaction with health care, and CAM use over the past year.

RESULTS

Parents completed 348 surveys. Forty percent (138) of parents were CAM users themselves, whereas 21% (72) had treated their child with CAM over the past year. Factors positively associated with child CAM use included parents' use of CAM (P <.0001); greater parent age (P =.0005); greater child age (P =.001); and complaints of frequent respiratory illnesses, asthma, headaches, and nosebleeds. Ethnicity and parental education were not associated with child CAM use. Over 50% of pediatric CAM users reported specific vitamin supplementation, whereas 25% used other nutritional supplements or elimination diets, and over 40% used herbal therapies. Thirty-two percent of CAM users had visited a CAM practitioner; 81% of pediatric CAM users would have liked to discuss it with their pediatrician, but only 36% did so.

CONCLUSION

Treatment of children with CAM is common and is frequently undertaken by parents without the knowledge or advice of their pediatrician.

Patients who always disagree with you

We are in no way suggesting that we should not be advocates of humane, scientifically based orthodox medicine and one gets the impression that even those patients who largely disagree with orthodox medicine keep coming back for advice, suggesting they also expect us to continue to do so. What we are advancing is an argument that our privileged background gives us a perspective that we cannot blame our patients for failing to share. Furthermore, our treatment style is a product of a particular time and place and must be changeable because of the scientific impetus behind medical practice. Because as GPs we live with uncertainty, we owe an open mind to our patients. Nevertheless we must advise them that when they venture into the world of the alternative they should avoid the expensive, the potentially harmful, and treatments that replace a safe conventional therapy about which we can show proof of benefit.